Massachusetts Licensed RN Utilization Reviewer

Job Summary

A company is looking for an RN Utilization Management Reviewer.

Key Responsibilities:

• Conduct timely clinical decision reviews for services requiring prior authorization across various clinical areas
• Apply established criteria and clinical expertise to determine the medical necessity of services
• Communicate review results to the primary care team, specialty providers, vendors, and members while ensuring compliance with regulations

Required Qualifications, Training, and Education:

• RN with an Associate's Degree required; Bachelor's Degree preferred
• Current RN license issued by the Massachusetts Board of Registration in Nursing
• 1 to 2 years of Utilization Management experience
• 2 or more years of experience working in a clinical setting
• CCM (Certified Case Manager) certification is a plus